Intracerebral Hemorrhage, Indication for Surgical Treatment and Surgical Techniques R

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68 The Open Critical Care Medicine Journal, 2011, 4, 68-71 Open Access Intracerebral Hemorrhage, Indication for Surgical Treatment and Surgical Techniques R. Reichart* and S. Frank

Department of Neurosurgery, Jena University Hospital, Friedrich-Schiller-University, Erlanger Allee 101, D-07747 Jena, Germany

Abstract: Intracerebral hemorrhage is a common disease. We give a short review of primary haemorrhages under neurosurgical aspects. Neurological symptoms depend on localisation and size of the hematoma. Only a subgroup of intracerebral haemorrhages is treated surgically. The STICH-trial tried to differentiate, in which cases the hematoma should be removed surgically. Surgical treatment could be performed by open craniotomy, endoscopic evacuation of the hematoma or CT-guided stereotaxy. Keywords: Intracerebral hemorrhage, neurosurgical treatment, ICH.

INTRODUCTION arterioles, in most cases associated with longterm arterial hypertension. Spontaneous rupture of these blood vessels Intracerebral hemorrhage (ICH) is a common disease due to reduced vessels elasticity and increased susceptibility with an incidence ranging from 11 to 23 cases per 100,000 [4]. Cerebral amyloid angiopathy is a common cause of ICH per year. Although it accounts for only 10 to 15% of all in the elderly, which is not associated with arterial strokes, it is the most fatal stroke subtype with a mortality up hypertension desease [4]. to 40 % [1]. While expanding, the intracerebral hematoma takes the Intracranial hemorrhages can be classified by anatomical path of lowest resistance and spreads along the neuronal or etiological aspects. According to anatomical fibres. Supratentorial located ICH causes rising of the considerations parenchymatous, subarachnoid, subdural, intracranial pressure if its volume is larger than 60ml or epidural, supra- and infratentorial hemorrhages have been more in the presence of an atrophy of the brain. Finally, found. rising tissue pressure and hemostasis finally stop bleeding. According to etiological aspects primary or spontaneous Raised tissue-pressure next to ICH causes danger of hemorrhages can be distinguished from secondary ischemia in this area, which leads to a cytotoxic brain edema hemorrhages. Primary haemorrhages are spontaneous within 24 to 48 hours, enlarging during the next days. These hemorrhages, which are mainly caused by arterial mechanisms result into a secondary raised intracranial hypertensive diseases. Secondary hemorrhages are due to pressure, which causes secondary neurological damages and traumatic, tumorous or pharmacological causes. This review needs further treatment. article will consider primary intracerebral hemorrhages only. SYMPTOMS In most cases primary intracerebral hemorrhages are caused by arterial hypertension, (in up to 90% of patients) or Depending on localisation and volume of the hematoma, by amyloid angiopathy. The localisation of the hematoma is ICH may cause different neurological deficits. Like in associated with the etiology of hemorrhage. Hypertensive ischemic insults, in ICH neurological symptoms are hemorrhages p.e. involve frequently basal ganglia, thalamus developed within minutes to hours. Symptoms of ICH can be or the posterior fossa. The primary hemorrhages based on divided into general manifestation and manifestations due to amyloid angiopathy may result in lobar hematomas, typically the localisation of hematoma. Normally, severe headaches at the border of the grey and white matter. But cerebral are described sometimes in combination with vomiting, amyloid angiopathy associated haemorrhages can also whereas an alteration in level of consciousness also could involve the subarachnoidal space or result in cerebellar occur. Symptoms of lobar ICH are associated with the hematomas [2,3]. affected cerebral lobe, so homonyme hemianopsia, paresis of arm or leg, or aphasia are observed. Small ICH of basal The exact etiology and pathophysiology of a primary ganglia could occur without any symptoms, but larger ICH intracerebral hematoma remain controversal. Primary in this region leads to sensomotoric contralateral intracerebral haemorrhages are caused of the rupture of small hemiparesis, sometimes in combination with aphasic disorders or homonymous hemianopsia, when the hematoma extends posteriorly and involves optic radiation. In ICH of *Address correspondence to this author at the Department of Neurosurgery, Pons severe neurological deficits are observed like coma, Jena University Hospital, Friedrich-Schiller-University Jena, Erlanger Allee 101, D-07747 Jena, Germany; Tel: ++49 +3641 9323023; Fax: ++49 +3641 disorders of pupillomotoric, abnormal flexions or extensions 9323021; E-mail: [email protected] of extremities. Cerebellar ICH typically causes nausea,

1874-8287/11 2011 Bentham Open Intracerebral Hemorrhage The Open Critical Care Medicine Journal, 2011, Volume 4 69 vomiting, and dizziness. Hydrocephalus may occur, if patient, ICH should have a diameter more than 2cm, and circulation pathways of CSF are obstructed, leading to an GCS should be better than 5. Hemorrhages caused by a alteration in level of consciousness. Larger cerebellar vascular abnormality, brain tumor or trauma were excluded, haemorrhages could lead to brain stem compression. In these as well as ICH located in the cerebellum or in the brain stem. cases an alteration in level of consciousness, tetraparesis or When randomized to the surgical treatment in about 75% paresis of cranial nerves could be observed. Hematomas craniotomy was done. The trial showed that there are no located exclusively intraventriculary usually cause headaches significant differences between surgical and non surgical only, although a secondary hydrocephalus can lead to treated groups. A good outcome was observed in 26% of the unconsciousness. surgical und 24% of the medical treated group. Even the mortality after 6 months was nearly identical: 36% versus DIAGNOSIS 37% respectively. Furthermore the trial showed that poor If ICH is suspected, cerebral imaging is obligatory. initial GCS (less than 9) is associated with poor outcome Cranial CT has a good sensitivity (more than 95%), however regardless of surgical or nonsurgical treatment. there are cases in which hemorrhage does not appear in The results of STICH are still discussed and interpreted cranial CT but are detected in MR-imaging (with T2* and in different ways. Two main points of view are criticized, protonweight sequences) [5]. Fiebach even reports of a which are undermining the results of this trial. First, 26% of sensitivity up to 100% when using MR-imaging [6]. Since initial medical treated patients shifted to surgical treatment computed Imaging is more available und easier in use an because of secondary detoriation (worsening of unenhanced CT-scan is the first choice for diagnostic consciousness, new neurological symptoms or rebleeding). examination. In young patients or patients with no Second, the including criteria have been set according to the preexisting arterial hypertension further diagnostic imaging clinical uncertainty principle, so due to multicentric trial (83 is advisable, using MR-angiography, CT-angiography, or hospitals in 27 countries) is was not possible to give a conventional digital substraction angiography [7]. definitely statement for all patients. THERAPY After all the STICH-trial showed that patients with It is point of dicussion for more than 100 years whether surficial hemorrhages (distance to cortex surface less than ICH should be evacuated surgically. Surgeons noticed that 1cm) seem to benefit from surgery. These results should be the prognosis for patients still remained poor, independently verified now by the STICH-2-trial. whether they were surgically treated or not. Up to 30% of all Only in a small part of ICH there is uncertainty whether patients suffering from ICH die within 30 days after stroke, surgery should be done or not. and many patients surviving ICH remain in a severe affected vegetative state. Thus the outcome of a large part of patients Small hemorrhages especially of the basal ganglias with is still unsatisfactory. Multiple attempts have failed to find small or absent neurological deficits should not be treated objective criteria to decide, whether surgery is useful or not surgically. (Fig. 2). But also in large hematomas damaging a in a single case, although the surgical techniques have been whole hemisphere, surgery is not advisable, especially in old improved during the recent years. patients in a poor neurological state. Still there does not exist any evidence by clinical trials, because randomising in this These questions should be finally answered by the case seems to be not acceptable for ethical reasons. STICH-trial (International Surgical Trial in Intracerebral Hemorrhage), a large randomized multicentric trial [8]. Patients suffering from medium-sized lobar ICH should Overall 1033 patients with spontaneous supratentorial ICH undergo surgery, particulary if GCS is below 7. (Fig. 1). have been enrolled within 72 hours after stroke. If there was Those showing small initial hematomas and detoriating in uncertainty of the advantage of surgical or medical clinical course, should also be treated surgically. treatment, the patient has been randomised. For enrolling a

Img 1 Img 2

Fig. (1). Basal ganglia ICH treated surgically. Basal ganglia ICH on the right side, showing a mass effect and resulting into upper herniation. Image 1 before surgical evacuation via open craniotomy, image 2 4 days after surgery, presenting now an infarction of A. cerebri media right side. 70 The Open Critical Care Medicine Journal, 2011, Volume 4 Reichart and Frank

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Fig. (2). Small ICH treated non-surgically. Small ICH of the basal ganglia (Img1), needing no further surgical treatment. Lobar ICH with surrounding edema (Img2), also medical treated.

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Fig. (3). Cerebellar ICH treated surgically. Cerebellar ICH with compression of the brain stem (Img1), developing a hydrocephalus through obstructing the CSF pathways (Img2). Dekompression of the posterior fossa and evacuation of the hematoma have been done immediately. (Img3).

Indication to surgery should be expressed generously if coagulated. Some authors described a better neurological cerebellar ICH is causing disorders in circulation of the CSF outcome compared to an open craniotomy or CT guided or ICH is affecting the brain stem by a mass effect. (Clinical stereotaxy in small groups, but further randomized trials are signs are reduction of consciousness, swallowing disorders, still missing [10,11]. or abducens palsy). (Fig. 3). In cases of small cerebellar hemorrhages and disorders in circulation of the CSF only a Computer Tomography (CT) - Guided Stereotaxy temporary external ventricular drain should be implanted, In 1960ies stereotactic aspiration of deep localised ICH but the hematoma itself should not be evacuated. has been developed as influenced by the development and introduction of computed imaging. Since coagulated SURGICAL THERAPIES hematomas are difficult to aspirate, urokinase may be Open Craniotomy and Evacuation of the Hematoma injected into the hematoma cavity for residual hematoma lyses and to enable draining the hematoma. Using this In principle craniotomy should be done in a way, that the procedure an inspection of the hematoma cavity is not hematoma can be reached on the shortest path as possible possible. Because of a poor bleeding control there is a higher avoiding further injury to eloquent brain-areas. After risk of rebleeding compared to both other surgical smallest possible incision, the cortex is forced apart techniques. CT-guided stereotaxy is used in some ICH, but with self-retaining spatula and the hematoma cavity is evidenced experience is missing to verify the effictiveness of Parts of the hematomas are removed with forceps, localised. this procedure [10-12]. while paying attention to avoiding new bleeding in margin zones of the hematoma. The use of an operation microscope SUMMARY AND CONCLUSION is advantageous for adequate hemostasis and satisfactory Primary intracerebral hemorrhage is a common disease. hematoma removal. Although surgical technique has been improved in recent Endoscopic Evacuation of the Hematoma time the prognosis for patients suffering from ICH still remains poor. Endoscopic guided evacuation of the hematoma with coagulation by neodym-laser is propagated in the end of the In large hemorrhages including the brain stem or the 1980ies [9]. Surgery can be performed through a single burr thalamus surgery is not advisable. hole. While evacuating the hematoma the direction of the In putaminal or lobar ICH the clinical state of the patient endoscope is changed to inspect all directions of the should be taken into consideration. Consciounent patients hematoma cavity for bleeding vessels, which could be with hematomas between 30 and 50 ml should undergo Intracerebral Hemorrhage The Open Critical Care Medicine Journal, 2011, Volume 4 71 medical treatment. Evacuating of larger hematomas in [4] Elijovich L, Pratik VP, Hemphill JC. Intracerebral Hemorrhage. unconsciounent patients could be lifesaving. Especially in Semin Neurol 2008; 28: 657-67. [5] Kidwell CS, Chalela JA, Saver JL, et al. Comparison of MRI and old unconsciounent patients showing signs of affection of the CT for detection of acute intracerebral hemorrhage. JAMA 2004; brain stem, the prognosis seems to be hopeless, thus surgery 292: 1823-30. is not advisable. If secondary neurological detoriation occurs [6] Fiebach JB, Schellinger PD, Gass A, et al. 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Received: November 3, 2009 Revised: March 18, 2011 Accepted: April 15, 2011

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